US 20090264922 A1
A device and method for closing a percutaneous vascular puncture with anchors at the distal ends of wires temporarily implanted in extravascular tissue adjacent the puncture. The wires are tensioned to draw the tissue together to approximate the edges of the puncture. The wires are retained in that position while the blood in the region of the arteriotomy clots. When hemostasis has been achieved, the anchoring wires then can be removed.
1. An apparatus for effecting hemostasis about a percutaneous vascular puncture comprising:
an elongate sheath having at least three passages including a central passage and a pair of needle passages;
a hollow needle slidably disposed within each needle passage, the distal end of each needle being pre-formed to assume a predetermined curved shape when relaxed, the needles being extendable distally from and retractable into their respective needle passages;
the needles and sheath being cooperatively arranged to direct the needles in substantially opposite directions when the needles are extended from their respective needle passages; and
a wire slidably disposed within a lumen of each needle, each wire having a distal end with a pre-formed shape, the wire distal end being adapted to be contained within the needle and to assume its pre-formed shape when extended distally beyond the distal end of the needle, the pre-formed shape defining an anchor adapted to securely engage tissue when assuming the pre-formed shape within tissue.
2. The apparatus as defined in
3. The apparatus as defined in
cooperative guides associated with the needles and their respective needle passages to prevent the needles from rotating within their respective passages.
4. The apparatus as defined in
5. The apparatus as defined in
each needle being provided with an external longitudinal groove and each needle passage being associated with a projection, the needle groove and needle passage projection being arranged to cooperatively mate to prevent rotation of the needle within the passage but to enable the needle to advance longitudinally out of the needle passage.
6. The apparatus as defined in
7. The apparatus as defined in
8. A method for effecting hemostasis about a percutaneous puncture in a blood vessel surrounded by extravascular tissue, the method comprising:
providing an elongate sheath having a pair of needles slidably disposed in a corresponding pair of needle passages, each needle having a lumen therethrough terminating in an open distal end, a flexible wire disposed in the lumen of each needle with each wire having a distal end disposed at the region of the distal end of the needle, the distal end of each wire being pre-formed into the shape of an anchor when unconstrained by the needles;
percutaneously advancing the sheath toward the puncture through extravascular tissue attached to the vessel, and locating a distal end of the sheath in proximity to the puncture;
advancing the needles out of their passages and directing the needles in opposite directions into the extravascular tissue, to pierce the extravascular tissue on opposite sides of the vascular puncture;
delivering the wire distal ends from the needle distal ends to allow the anchors to form within the tissue to securely engage the tissue;
withdrawing the needles into their passages and urging the wires into the needles, thereby drawing the anchors together to draw the tissue together, thereby drawing the edges of the puncture toward each other; and
maintaining the position of the anchors until hemostasis is achieved.
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10. The method as defined in
11. The method as defined in
orienting the needles so that they are disposed along a medial plane of the blood vessel before the needles are withdrawn from the tissue.
12. The method as defined in
after hemostasis is achieved, advancing the needles out of their passages and recovering the wire distal ends into the needles to disengage the anchors from the tissue; and
removing from the extravascular tissue the sheath and the needles and the wires.
The invention relates to devices and techniques for effecting hemostasis about a puncture in a blood vessel after an intravascular procedure.
Various cardiovascular procedures, such as angioplasty and stent placement among others, are performed by inserting into and manipulating within a patient's vasculature, wires and catheters adapted to perform those procedures. In coronary and other such vascular interventional procedures access to the vasculature typically is percutaneous, often through the femoral artery, involving insertion of a needle in the region of the groin to form a track through subcutaneous tissue and to puncture and create an arteriotomy in the artery. A short guidewire then is advanced through the needle and into the femoral artery. The needle then is removed and a dilator carrying an introducer sheath then is advanced over the guidewire, along the needle track and into the femoral artery. The dilator enlarges the track through the tissue and widens the puncture in the vessel so that it may receive subsequent guidewires, catheters and the like. With the introducer sheath having been advanced into the vessel, the dilator and short guidewire are removed leaving the sheath in place. The sheath provides access into the femoral artery, through the arteriotomy, for catheters or other instrumentalities in order to perform the selected procedure.
After the procedure has been completed, the procedural devices are removed and the arteriotomy must be closed. A number of techniques are known to facilitate closure and healing of the arteriotomy. These include application of pressure at the puncture site for a relatively extended length of time, or the use of biological adhesives or plugs adapted to seal the arteriotomy, or the use of staples or clips. Some closure systems include an arrangement to engage the artery to temporarily draw the edges of the arteriotomy together while a final closure device, such as a stapler, sutures, adhesives or other means is used to effect the permanent closure of the arteriotomy. Some of these systems result in piercing the vessel wall or other tissue, such as systems described, for example, in U.S. Pat. No. 6,767,356 (Kanner) and U.S. Pat. No. 6,391,048 (Ginn et al.).
It would be desirable to provide an alternate system for effecting hemostasis of a vascular puncture wound without risking the trauma that may result from piercing the vascular wall and also to avoid the risk of a closure element projecting into the interior of the vessel lumen. The present invention is directed to such an alternative device and technique.
The invention employs a percutaneously placeable closure device that can be advanced along a track or over an indwelling guidewire and by which tissue located close to, but exteriorly of, the blood vessel wall can be gripped on opposite sides of the puncture and then drawn together. Tissue immediately adjacent the blood vessel that is attached to the outer surface of the blood vessel thus may be drawn together to draw portions of the vessel wall toward each other. By engaging the tissue on opposite sides of and in close proximity to the puncture, the edges of the puncture can be approximated without piercing the vessel wall.
A device for implementing the invention may include a sheath that contains a pair of hollow needles having sharp distal tips and pre-curved distal ends that are sufficiently flexible that they can be straightened and withdrawn into receptive passages in an elongate delivery sheath. Each hollow needle contains a flexible wire having a distal end pre-formed with a shape capable of self-anchoring within tissue when deployed within the tissue. The wire and pre-formed distal anchoring shape are such that the distal end of the wire can be retracted into the lumen of its associated needle with the anchor portion assuming a straightened shape. The needles and sheath are arranged so that as the needles emerge from the distal end of the sheath they extend in opposite directions, preferably lengthwise of the blood vessel.
The device may be used by advancing the delivery sheath along a guidewire and/or the existing puncture track to position the distal end of the sheath proximal to the outer surface of the blood vessel in the region of the puncture wound. The distal end of the sheath may be positioned with respect to the vessel puncture by means of a blood marking tube having a distal blood marking port that, when entering the blood vessel, enables blood to flow through the tube to provide an indication to the clinician at the proximal end of the tube that the vessel has been reached. The distal end of the sheath and the blood marking port are associated to indicate when the distal end of the sheath is in the proper position. The needles then are advanced through the sheath and, as they emerge from their respective passages, will assume their curved configurations in opposite directions. Preferably the needles extend in approximately a common plane that extends longitudinally of the blood vessel and generally perpendicular to the orientation of the vessel puncture. Means are provided to guide the needles in that orientation. When the curved needles have been extended into the desired depth in the tissue and with the distal ends of the wires extending to the distal end of the needle lumens, the needles are retracted while the wires are maintained in place. As the needles retract, the distal ends of the wires are freed from the restraint of the needles and assume the pre-formed anchor configuration within the tissue. With the anchors secured to the tissue, the wires then are tensioned to draw the tissue together that, in turn, draws the edges of the vessel puncture together. The wires are retained in that position while the blood in the region of the arteriotomy clots, resulting in hemostasis. External pressure also may be applied, as by manual compression, for example. When hemostasis has been achieved, the anchoring wires then can be removed by re-advancing the needles distally over the extended wires. As the needles advance over the wires, the anchor configurations are straightened and recaptured into the needle lumens. The device then may be withdrawn from the patient.
The foregoing and other features and advantages of the present disclosure will be apparent from the following description of the disclosure as illustrated in the accompanying drawings. The accompanying drawings, which are incorporated herein and form a part of the specification, further serve to explain the principles of the disclosure and to enable a person skilled in the pertinent art to make and use the disclosure. The drawings are not to scale. In the accompanying drawings:
The terms “distal” and “proximal” are used in the following description with respect to a position or direction relative to the treating clinician. “Distal” or “distally” are a position distant from or in a direction away from the clinician. “Proximal” and “proximally” are a position near or in a direction toward the clinician.
After the vascular procedure has been completed, the procedural devices are removed and the arteriotomy must be closed. The present invention employs a technique in which the edges 20 of the arteriotomy 14 are drawn together by engaging and drawing together tissue 12 that is external of and adjacent to the vessel wall in the region of the arteriotomy. That adjacent tissue may be comprised of fascia, membranes such as the femoral sheath, and fatty tissue. The tissue immediately adjacent the outer surface of the vessel often is attached to the vessel wall sufficiently so that the tissue, which had been separated to form the track along which the needles, guidewires, dilators and catheters were advanced, can be drawn together. The present invention employs an arrangement by which such extravascular tissue 12 can be engaged and drawn together, thus drawing together the edges 20 of the arteriotomy to which the extravascular tissue is attached.
Hollow needles 34, 36 are contained slidably within the passages and are guided so that they can emerge from the distal ports 30, 32 and extend in diametrically opposite directions. The distal ends 38, 40 of the needles 34, 36 are pre-formed so that when unconstrained, they will assume a selected curved configuration. The needles may be formed from nitinol hypotubing and, for example, may have an outer diameter of between about 0.020 inch to about 0.030 inch with a wall thickness of about 0.005 inch. The curved configuration at the distal end of the needles should be such that when the needles have curved so that their distal tips extend in forward and rearward directions, generally paralleling the vessel, they have penetrated the tissue to a sufficient depth to facilitate placement of the anchors, as described below. By way of example, the distal tips of the needles may penetrate into the tissue of the order of about ⅜ to ⅝ inch.
In order to guide the emerging needles in opposite directions along the medial planes 21, 23, the needles and needle passages are provided with guides. To this end, the needles 34, 36 may be formed to include longitudinally extending grooves respectively 35, 37 in the wall of the needle. Such grooves may be formed by stamping or roller swaging or by other techniques known to those familiar with the art of hypotube manufacture or similar small tube manufacture. The sheath 22 may be provided, within each of the needle passages 26, 28, with elongate ribs 39, 41 adapted to engage the grooves in the respective needles. In the present example, elongate ribs 39, 41 extend along the medial plane 23, but the ribs may be positioned at any radial location around the needle passages 26, 28. The ribs 39, 41 may be formed continuously along the inner diameter of the needle passages 26, 28 or may be in the form of a projection at the distal end of each needle passage shaped and oriented to engage the needle grooves 35, 37 as they emerge from their respective lumens. In an alternative embodiment (not shown), the needles 34, 36 may be formed to have longitudinally extending ribs and the needle passages 26, 28 may have elongate groves adapted to engage the ribs on the respective needles.
In another embodiment (not shown), the needles 34, 36 may be formed with a non-circular cross-sectional shape, such as an oval or polygon, and the needle passages 26, 28 may have a similar non-circular cross-sectional shape adapted to engage and guide the emerging needles in opposite directions along the medial planes 21, 23.
Delivery sheath 22 may be made from a unitary plastic extrusion having the desired profile to provide central passage 24 and needle passages 26, 28. Some examples of suitable biocompatible thermoplastics for melt-extruding sheath 22 are high density polyethylene (HDPE), rigid polyethylene block amide copolymer (PEBA), and fluoroethylene-propylene (FEP). Polytetrafluoroethylene (PTFE) resin is also an example of a material suitable for paste or “cold” extrusion of sheath 22. Alternatively, sheath 22 made be made of discrete tubes for providing central passage 24 and needle passages 26, 28, the tubes being bundled and held together by polymer tubing shrink-fitted around the tubes. Each of the discrete tubes can be made from metal tubing, e.g., nitinol or stainless steel, or from a suitable polymer. The exterior surface of sheath 22 need not be cylindrical.
In order to position the distal end of the sheath at the desired depth within the tissue track 18, a blood marking tube 60 may be employed as shown in
When the needles are embedded within extravascular tissue associated with opposite sides of the arteriotomy, the wires associated with the needles are advanced, if not already in position, until their distal ends extend to the tips of the needles (
After the ends of the wires assume their anchor configuration secured within the tissue on opposite sides of the arteriotomy (
It should be understood that the foregoing description of the invention is intended merely to be illustrative thereof and that other embodiments, modifications and equivalents may be apparent to those skilled in the art while remaining within the scope of the invention. Although the apparatus of the invention has been described above as having only one pair of needles 34, 36 containing wires 42, 44, the invention is not so limited. Thus, the invention may incorporate more than two needles and a corresponding number of wires, arranged such that the plurality of needles emerges from the delivery sheath and places the wire anchors in a pattern for drawing together the intravascular tissue adjacent the vascular puncture.